NPIMap

Individual provider Active NPI

Casey L. Wallace, PT, DPT

  • Physical Therapist
  • Virginia Beach, VA
National Provider Identifier
1134474323
Registry record updated Mar 22, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physical TherapistTaxonomy code 225100000X
License
2305207461 Issued in VA
Practice address
984B Laskin Rd
Virginia Beach, VA 23451-3905
Phone
(757) 395-6900
Fax
(757) 425-7180
NPI assigned
Jul 13, 2012
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Mar 22, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Physical Therapist 225100000X 2305207461 VA Primary

Addresses

Primary practice location

984B Laskin Rd
Virginia Beach, VA 23451-3905

Mailing address

984B Laskin Rd
Virginia Beach, VA 23451-3905
Phone (757) 395-6900

Other practice location 1

204 Gumwood Dr
Smithfield, VA 23430-6087
Phone (757) 357-7762

Other identifiers 2

IdentifierTypeStateIssuer
C05954OtherVAGROUP MEDICARE PTAN
1134474323MedicaidVA

Other names 1

  • Casey L Fioravante Former name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in VA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20120919000732 VA Practitioner - Physical Therapist in Private Practice 4082862834 Reassigns benefits to 1 organization

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled

State licenses

LicenseStateTypeSpecialty
2305207461VAMDPhysical Therapist

Practice roles

OrganizationSpecialtyStatusNew patients
Tidewater Physical Therapy LLC Physical Therapist Past Accepting new patients
Tidewater Physical Therapy LLC Physical Therapist Past Accepting new patients
Tidewater Physical Therapy, LLC Physical Therapist Past Accepting new patients
Tidewater Physical Therapy LLC Physical Therapist Past Accepting new patients
Tidewater Physical Therapy, LLC Physical Therapist Past Accepting new patients

Organizations & group practices 6

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1342137600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1616371200000",
    "number": "1134474323",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "984B LASKIN RD",
            "city": "VIRGINIA BEACH",
            "state": "VA",
            "postal_code": "234513905",
            "telephone_number": "757-395-6900",
            "fax_number": "757-425-7180"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "984B LASKIN RD",
            "city": "VIRGINIA BEACH",
            "state": "VA",
            "postal_code": "234513905",
            "telephone_number": "757-395-6900",
            "fax_number": "757-425-7180"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "204 Gumwood Dr",
            "address_purpose": "LOCATION",
            "city": "Smithfield",
            "state": "VA",
            "postal_code": "234306087",
            "country_code": "US",
            "telephone_number": "757-357-7762",
            "fax_number": "757-357-7765",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "CASEY",
        "middle_name": "L.",
        "credential": "PT, DPT",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2012-07-13",
        "last_updated": "2021-03-22",
        "certification_date": "2021-03-22",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "VA",
            "license": "2305207461",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "GROUP MEDICARE PTAN",
            "identifier": "C05954",
            "state": "VA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1134474323",
            "state": "VA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "CASEY",
            "last_name": "FIORAVANTE",
            "middle_name": "L",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

Other providers in Virginia Beach, VA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 22, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.